Randomized placebo-controlled trial of CDB-2914 in new users of a levonorgestrel-releasing intrauterine system shows only short-lived amelioration of unscheduled bleeding

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive. However, during early months of use unscheduled vaginal bleeding is common, sometimes leading to discontinuation. This study aimed to determine whether intermittent administration of progesterone receptor modulator CDB-2914 would suppress unscheduled bleeding during the first 4 months after insertion of the LNG-IUS.

METHODS

CDB-2914 150 mg, in divided doses, or placebo tablets, were administered over three consecutive days starting on Days 21, 49 and 77 after LNG-IUS insertion, in a double-blind randomized controlled trial of women aged 19-49 years, newly starting use of LNG-IUS. Daily bleeding diaries were completed for 6 months, and summarized across blocks as percentage days bleeding/spotting (BS%).

RESULTS

Of 69 women randomized to receive CDB-2914, and 67 placebo, 61 and 55, respectively, completed the trial. BS% decreased with time in both arms, but showed a much steeper treatment-phase gradient in the placebo arm (P < 0.0001), so that a benefit of CDB-2914 in the 28 days after first treatment (-11% points, 95% CI -19 to -2), converted to a disadvantage by 64 days after the third treatment (+10% points, 95% CI 1-18).

CONCLUSIONS

The effect of CDB-2914 on BS% was initially beneficial but then by third treatment was disadvantageous. Nevertheless, only 3% (4/136) of all women discontinued LNG-IUS. These findings give insight into possible mechanisms and suggest future research directions. ISRCTN Trial no. ISRCTN58283041; EudraCT no. 2006-006511-72.

A novel estrogen-free oral contraceptive pill for women: multicentre, double-blind, randomized controlled trial of mifepristone and progestogen-only pill (levonorgestrel)

BACKGROUND

The acceptability and continuation rate of oral contraceptive steroids are limited by unpredictable bleeding and the fear of long-term risks such as breast cancer. By inhibiting ovulation and by altering the receptivity of the endometrium, antagonists of progesterone, such as mifepristone, could be developed as estrogen-free novel contraceptives.

METHODS

Multicentre, double-blind, randomized controlled trial comparing frequency of amenorrhoea (primary outcome), bleeding patterns, side effects and efficacy in women taking daily 5 mg mifepristone (n = 73) or 0.03 mg levonorgestrel (progestogen-only pill; POP, n = 23) for 24 weeks.

RESULTS

More women were amenorrhoeic while taking mifepristone than POP (49 versus 0% P < 0.001), and fewer women bled or spotted for >5 days per month (4 versus 39% P < 0.001). Forty-eight percent of women who took mifepristone for 6 months had cystic glandular dilatation of the endometrium but none showed hyperplasia or atypia. There were no pregnancies in 356 months of exposure in women who used only mifepristone for contraception. Two pregnancies occurred in women taking mifepristone who were also using condoms for dual protection.

CONCLUSIONS

Daily mifepristone (5 mg) is an effective oral contraceptive pill which has a better pattern of menstrual bleeding than an existing POP (levonorgestrel).

Are routine breast and pelvic examinations necessary for women starting combined oral contraception?

Millions of women worldwide use combined oral contraception (COC). Most of them are in good health and have no contraindications to using any contraceptive method. Although extremely safe for the vast majority of women and even though the absolute risk of complications is very small, COC is associated with an increased relative risk of serious conditions including cardiovascular disease and breast and cervical cancer. In many countries, breast and pelvic examinations are routinely undertaken annually for all women using hormonal contraception. Breast and pelvic examination have low detection rates for abnormality and may yield clinically irrelevant results, causing anxiety and inconvenience to the patient for no obvious gain. There is no good evidence to support routine breast or pelvic examination either for women starting hormonal contraception or for monitoring long-term use.

Amenorrhea associated with contraception-an international study on acceptability

Surveys undertaken in the 1970s and 1980s suggested that amenorrhea was unacceptable to most women, especially in developing countries. More recent research suggests that increasing numbers of women in the developed world prefer to menstruate less often. In a questionnaire survey of 1001 women attending family-planning clinics and 290 contraceptive providers in China, South Africa, Nigeria and Scotland, only among black women in Africa did the majority like having periods. In all other groups, most women disliked periods, which were "inconvenient" and associated with menstrual problems. Given the choice, the majority of Nigerian women would prefer to bleed monthly. Elsewhere, women would opt to bleed only once every 3 months, or not at all. In all except the Chinese centers, the majority of women would be willing to try a contraceptive which induced amenorrhea. Providers tended to overestimate the importance of regular menstruation to their clients. This is an important observation for scientists and funding agencies involved in developing new methods of contraception.

Is postpartum contraceptive advice given antenatally of value?

In response to the concept that a good postpartum program should begin prenatally, this study was designed to determine whether the provision of expert contraceptive counseling during the antenatal period would have an impact on contraceptive uptake, patterns of contraceptive usage, and pregnancy rates during the first year after childbirth. Over 500 women attending antenatal clinics in each of three centers (Edinburgh, Scotland; Shanghai, People's Republic of China; Cape Town, South Africa) were randomized to receive expert contraceptive advice (participants, n = 771) or the standard advice routinely given in that setting (controls, n = 866). Follow-up was by postal or interviewer-administered questionnaires at 16 and 52 weeks after childbirth. There were no significant differences in the prevalence of contraceptive use at one year (over 79% in all centers) between participants and controls. In Edinburgh, participants were more likely to undergo sterilization (p < 0.01) than controls, otherwise there were no differences among Edinburgh, Shanghai, or Cape Town in either the methods of contraception chosen or in the methods used over time. Contraceptive counseling delivered antenatally appeared to have no impact on the pregnancy rate during the first year after childbirth. In Shanghai, over 11% of women in both groups underwent termination of pregnancy in the year of follow-up. In conclusion, although women in all centers said they found the opportunity to discuss contraception antenatally was useful, it had very little effect on contraceptive use or on subsequent pregnancy rates.

Noncompliance among a group of women using a novel method of contraception

OBJECTIVE

To compare the incidence of noncompliance measured objectively by a home use fertility monitor with the traditional self-reported incidence of compliance in a study of a new method of contraception.

DESIGN

Prospective cohort study.

SETTING

A large family planning clinic in Edinburgh.

PATIENT(S)

Thirty-two healthy women who took part in a trial assessing the efficacy of a novel method of contraception involving accurately timed administration of a single dose of mifepristone.

INTERVENTION(S)

Mifepristone was administered orally and a blood sample was collected on the same day.

MAIN OUTCOME MEASURE(S)

Percentage of missed tests detected by the monitor against the self-reported percentage during the critical period.

RESULT(S)

Women failed to perform 24.2% (95% confidence interval, 16.5-31.5) of the tests in the 162 cycles analyzed. They missed tests at an absolutely vital time for contraceptive efficacy in 42% of cycles according to the monitor while admitting to missing tests in 14.8%. Poor compliance was associated with younger women, those who discontinued the study before completion, and cycles in which women were not relying on the contraceptive method.

CONCLUSION(S)

The use of microelectronic monitoring systems may improve our understanding of the extent of patient noncompliance, providing objective information that no other monitoring technique can produce. This understanding provides the opportunity to make the optimum use of potentially effective treatments while validating research evidence.

Feasibility of administering mifepristone as a once a month contraceptive pill

Many women find the idea of a once-a-month contraceptive pill an attractive concept. Mifepristone has been shown to be effective as a contraceptive if administered in the early luteal phase. We tested the contraceptive efficacy of 200 mg of mifepristone on day luteinizing hormone (LH) + 2 in a group of 32 women who used a fertility monitor to identify the LH surge. We also recruited a control group, comprising 20 women who were trying to conceive. In this group, 12 women conceived during a total of 50 control cycles (probability of pregnancy 0.25-0.32). Women in the treatment group contributed to a total of 178 cycles and there were two pregnancies (probability of pregnancy 0.01). An LH surge was not detected in 34 cycles (19.1%). In 20 cycles (11.2%) this was due to imperfect use while 14 were monitor method failures (7.9%). Treatment with mifepristone in the early luteal phase did not disrupt the cycle length but women reported slight vaginal bleeding in 15% of the cycles. The combination of a home-use fertility monitor with once-a-month administration of mifepristone (especially if mifepristone is administered at the early luteal phase) is an acceptable contraceptive option with minimal side effects. Unfortunately, it is difficult to envisage how an easier way of defining the correct timing, which required less compliance, could be devised.

The effects of peri-ovulatory administration of levonorgestrel on the menstrual cycle☆

Levonorgestrel (LNG) 0.75 mg administered 12 h apart within 72 h of unprotected coitus, is an established method of emergency contraception (EC). The mechanism of action of LNG used in this manner is unknown. We administered LNG 0.75 mg twice immediately before ovulation, to test the hypothesis that LNG acts as an emergency contraceptive by abolishing the pre-ovulatory lutenizing hormone (LH) surge and thereby delaying ovulation. Twelve women took LNG on or before the day of the first significant rise in urinary LH in 12 cycles. In four women, the LH peak and the onset of next menses were significantly delayed (delay of 16.8 days (SD +/- 8.7) from the day of mean LH peak in placebo cycles). One woman did not ovulate at all, despite a normal LH peak and cycle length. In the remaining eight women, LNG did not affect ovulation or the cycle length, but the length of the luteal phase and the total luteal phase LH concentrations were significantly reduced. We suggest that LNG acts as an emergency contraceptive by other mechanisms as well as delaying the LH surge and interfering with ovulation.

Would women trust their partners to use a male pill?

Despite a renewed interest in the development of hormonal contraceptives for men, many discussions about the potential acceptability of a 'male pill' end by speculating whether women would trust their partners to use the method reliably. To determine the views of women, we undertook a survey of 1894 women attending family planning clinics in Scotland (450), China (900) and South Africa (544). In all centres over 65% of women thought that the responsibility for contraception falls too much on women. More than 90% in South Africa and Scotland thought that a 'male pill' was a good idea, with Chinese women (71% in Hong Kong and 87% in Shanghai) only slightly less positive. Only 13% of the total sample did not think that hormonal male contraception was a good idea and only 36 women (2% of the total) said that they would not trust their partner to use it. 78% of Scottish women, 71% of Shanghai women, and 78% of white women and 40% of black and coloured women in Cape Town thought that they would use the method. This survey should dispel the myth that women would not trust their partners to use a 'male pill' reliably and illustrates the potential market for the method.

Potential impact of hormonal male contraception: cross-cultural implications for development of novel preparations

The prospect of a hormonal male contraceptive is no longer distant. Data on the potential impact of this improvement in contraceptive provision, however, is limited, particularly between different cultures. We have therefore carried out a multi-centre study to assess men's attitudes to proposed novel hormonal methods. Questionnaire-based structured interviews were administered to men in Edinburgh, Cape Town, Shanghai and Hong Kong. Approximately 450 men were interviewed in Edinburgh, Shanghai and Hong Kong, and a slightly larger group (n = 493) in Cape Town to give samples (n > 150) of black, coloured and white men. Knowledge of existing male and female methods of contraception was high in all centres and groups. The majority of men welcomed a new hormonal method of contraception, 44-83% stating that they would use a male contraceptive pill. Overall, a pill was more acceptable than an injectable form (most popularly given at 3-6 month intervals); long-acting implants were least so except in Shanghai. Familiarity with comparable female methods appeared to influence acceptability, for both oral and injectable methods. Hong Kong was the only centre where a male method (condom) was currently the most commonly used; men there appeared to rate the convenience of condoms highly while being least likely to think that they provided effective protection against pregnancy compared to other centres, and were least enthusiastic about novel male methods. The acceptability of potential male hormonal methods of contraception was high in some groups but showed wide variability, determining factors including cultural background and current contraceptive usage. These results suggest that the emerging emphasis that men should have greater involvement in family planning will be substantiated when appropriate contraceptive methods become available.

An international study on the acceptability of a once-a-month pill

Totals of 450 women attending family planning clinics in Hong Kong, Shanghai and Edinburgh, and 468 in Cape Town, completed a questionnaire designed to seek their views on a contraceptive pill which would be taken only once each month. At least two-thirds of the women in all centres liked the idea of a once-a-month pill. In Hong Kong, Cape Town and Edinburgh, women preferred a pill which inhibited ovulation to one which inhibited implantation, while in all centres a pill which worked after implantation (early menstrual inducer) was considered unacceptable by over half the women. A pill which was taken after a missed menstrual period was considered preferable in all centres, perhaps because it would not be used every month but rather only if pregnancy had occurred. No demographic characteristics, contraceptive experiences or beliefs were consistently correlated with attitudes towards a once-a-month pill, except that women who would not consider having an abortion were more likely to dislike a method that either prevented, or worked after, implantation. A once-a-month pill is now technically possible, although the major drawback is the need to determine when it should be taken. It is reassuring that many women from a variety of different cultures and with widely different experiences, would find this an attractive approach to contraception.

Regulation of matrix metalloproteinase-9 in endometrium during the menstrual cycle and following administration of intrauterine levonorgestrel

Remodelling of endometrial tissues is fundamental to the cyclical changes that occur during the menstrual cycle, implantation and, in the absence of pregnancy, at menstruation. The enzyme matrix metalloproteinase-9 (MMP-9) is recognized as important in these processes but its regulation is not well defined. These studies have demonstrated that MMP-9 activity is present in the endometrium and exhibits cyclical changes in its distribution in the glandular and stromal cells. MMP-9 protein is present throughout the cycle with highest expression, as determined by semiquantitative analysis of specific MMP-9 immunoreactivity, in glandular cells during the mid secretory phase. A similar distribution was observed in first trimester decidua. In women with a levonorgestrel intrauterine system (LNG-IUS), which delivers high local concentrations of progestagen to the uterine cavity, MMP-9 is highly expressed in both endometrial glandular and stromal cells, and in the vasculature (in endothelial and perivascular cells). It can be concluded that MMP-9 is stimulated directly or indirectly by progesterone. Furthermore, MMP-9 may play a role in the remodelling of the endometrium that occurs during the menstrual cycle and in the aetiology of the morphological changes and breakthrough bleeding associated with long-term progestagen administration via a LNG-IUS.

Progestin receptor isoforms and prostaglandin dehydrogenase in the endometrium of women using a levonorgestrel-releasing intrauterine system

This study has examined endometrial tissue in 14 normal women prior to insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) and thereafter longitudinally for up to 12 months post-insertion. The specific endpoints examined by immunohistochemistry were progesterone receptor (PR) subtypes A + B, oestrogen receptor (ER) and prostaglandin dehydrogenase (PGDH). Two antiprogesterone receptor antibodies, one specific to PR(B) subtype and the other to PR subtype A + B, were employed to examine the localization of both PR isoforms. The activity of PGDH, a progesterone dependent enzyme, was also measured. ER and PR(A+B) and PR subtype B were significantly down-regulated in glands and stroma in the presence of continuous intrauterine LNG delivery. There was an apparent increase in PR(A) immunoreactivity in endometrial glands between 6 and 12 months post-insertion. Consistent with down-regulation of both isoforms of PR was reduced glandular PGDH immunostaining following LNG-IUS insertion, and PGDH activity (as measured by metabolism of excess substrate in vitro). Furthermore, PGDH activity, known to be localized in the glands, significantly increased (P < 0.05) at 12 months post-insertion, coinciding with the observed increase in glandular PR(A+B) immunoreactivity at this time. Since the LNG-IUS suppresses the PR(B) so strongly, PR(A) is likely to be the subtype that mediates long term LNG action in the endometrium. PR(B) is the more suppressed of the two subtypes, and only PR(A) rises along with PGDH activity. Alterations to normal endometrial morphology and function, e.g. perturbation of normal sex steroid receptor expression, following exposure to high concentrations of local LNG, may play a role in the aetiology of bleeding disorders associated with the LNG-IUS. Further elucidation of local uterine mediators involved in the mechanism of bleeding problems is required.

Morphological and functional features of endometrial decidualization following long-term intrauterine levonorgestrel delivery

Irregular bleeding remains a common reason for the discontinuation of progestin-only contraception. The levonorgestrel releasing intrauterine system (LNG-IUS) has profound morphological effects upon the endometrium. Specific features are gland atrophy and extensive decidual transformation of the stroma. Morphological changes in the endometrium may be associated with perturbation of mechanisms regulating normal endometrial function. This study describes endometrial stromal and glandular features prior to and up to 12 months following insertion of the LNG-IUS. Comparison is made with first trimester decidua. In order to elucidate further mechanisms governing endometrial function with local intrauterine delivery of LNG, we here report histological features consistent with decidualization; a significant increase in granulocyte-macrophage colony stimulating factor (GM-CSF) immunoreactivity in decidualized stromal cells; glandular and stromal prolactin receptor expression and an infiltrate of CD56 + large granular lymphocytes and CD68 + macrophages. We are unaware of previous reports which have documented longitudinally both morphological and functional observations in endometrium exposed to local intrauterine levonorgestrel delivery. These studies demonstrate that long-term administration of intrauterine levonorgestrel results in features of altered morphology and function. No correlation was apparent between the end points in the study and the bleeding patterns described by the subjects. Further evaluation of these features in the context of menstrual bleeding experience may contribute to a better understanding of this troublesome side-effect which often leads to dissatisfaction and discontinuation of the intrauterine system.

Continuous transdermal oestrogen and interrupted progestogen as a novel bleed-free regimen of hormone replacement therapy for postmenopausal women

OBJECTIVE

To investigate the effects of a hormone replacement therapy regime of continuous oestrogen and interrupted progestogen, administered transdermally, on the endometrium of postmenopausal women, the pattern of bleeding and relief of menopausal symptoms.

DESIGN

Volunteer pilot study of up to six months duration involving weekly application of an oestrogen-only skin patch releasing 50 microg oestradiol per day interspersed with a combined oestrogen and progestogen patch releasing 50 microg oestradiol and 250 microg norethisterone acetate per day for three days. Transvaginal ultrasound measurements of endometrial thickness and endometrial biopsies were performed in the third month of treatment at the end of both an oestrogen-only phase of treatment and a combined oestrogen-progestogen phase.

SETTING

Specialist community menopause clinic, Dean Terrace Centre, Edinburgh.

PARTICIPANTS

Fifteen healthy postmenopausal women.

MAIN OUTCOME MEASURES

Effect of treatment on endometrial histology, the immunolocalisation of oestrogen and progesterone receptors and the cell proliferation marker Ki 67 after three months of treatment and the proportion of women without bleeding at six months.

RESULTS

Treatment provided relief of hot flushes and by the sixth month of study 10 of the 14 women who completed treatment had no vaginal bleeding (71%). No endometrial hyperplasia or atypical changes were observed in biopsies and ultrasound measurements of endometrial thickness demonstrated a thin endometrium. Reduced immunostaining for Ki 67 was observed in endometrium from the combined phase of treatment compared with the oestrogen-only phase, consistent with a progestogenic-antagonism of proliferation. Exposure to progestogen did not suppress steroid receptors as similar immunostaining was observed in both treatment phases.

CONCLUSIONS

Continuous oestrogen and interrupted progestogen administered transdermally offers promise as a novel bleed-free hormone replacement therapy for postmenopausal women.

Impact of the introduction of new medical methods on therapeutic abortions at the Royal Infirmary of Edinburgh

OBJECTIVE

To assess the impact of the introduction of new medical methods on the provision of therapeutic abortions at the Royal Infirmary Edinburgh.

DESIGN

A review of the total number of abortions performed by medical and surgical means between 1989 and 1995 (inclusive); a prospective survey of the terminations of pregnancy (< or = 9 weeks of gestation) performed over the six-month period of January to June 1994; and a questionnaire of the reasons why women chosen a particular method.

SETTING

Large teaching hospital in Scotland.

SUBJECTS

One thousand and seven women seeking early pregnancy termination between January and June 1994.

MAIN OUTCOME MEASURES

Proportion of pregnancies terminated by medical means; comparison of complete abortion rate, incidence of complications and morbidity following both medical and surgical methods (< or = 9 weeks of gestation); reasons for preference of the method of abortion.

RESULTS

Since 1991 there has been a progressive increase in the number of medical abortions performed at the Royal Infirmary of Edinburgh, and by 1994 the majority of women (57%) seeking abortion at < or = 9 weeks chose a medical method. Women who chose medical abortion had more years at full-time education and were less likely to smoke (P < 0.04). Both medical and surgical methods were highly effective (> 96% complete abortion) with a low incidence of complications and morbidity. However, women who had chosen the medical method were less likely to receive antibiotics for suspected endometritis than their surgical counterparts (chi 2, P = 0.0001).

CONCLUSIONS

If this trend towards medical methods in Edinburgh is repeated elsewhere, it will inevitably have an impact on gynaecological services by releasing staff and operating time for other purposes.

Teenagers' knowledge of emergency contraception: questionnaire survey in south east Scotland

OBJECTIVE

To determine the level of knowledge of emergency contraception among 14 and 15 year olds.

DESIGN

Confidential questionnaire survey.

SETTING

10 secondary schools in Lothian, south east Scotland.

SUBJECTS

1206 pupils predominantly (98.7%) aged 14 and 15 in the fourth year of secondary school.

MAIN OUTCOME MEASURES

Knowledge of the existence of emergency contraception; of its safety, efficacy, and time limits; and of where to obtain it.

RESULTS

1121 (93.0%) fourth year pupils aged 14-16 had heard of emergency contraception. 194 girls (32.7%) and 168 boys (27.5%) had experienced sexual intercourse. Of girls who had experienced sexual intercourse, 61 (31.4%) had used emergency contraception. Knowledge of correct time limits was poor, sexually active girls being the most knowledgeable. Pupils attending schools ranked lower than the national average for academic attainment were less likely to have heard of emergency contraception and more likely to have been sexually active. 861 (76.8%) pupils knew they could obtain emergency contraception from their doctor. 925 (82.5%) pupils believed emergency contraception to be effective but 398 (35.5%) thought it more dangerous than the oral contraceptive pill.

CONCLUSIONS

One third of sexually active girls aged under 16 in Lothian have used emergency contraception. This may help explain the fairly constant teenage pregnancy rates despite increasing sexual activity. Scottish teenagers are well informed about the existence of emergency contraception. However, many do not know when and how to access it properly. Health education initiatives should target teenagers from less academic schools as they are more likely to be sexually active at a young age and are less well informed about emergency contraception.

Twenty-four hour patterns of prolactin secretion during lactation and the relationship to suckling and the resumption of fertility in breast-feeding women

In breast-feeding women prolactin released in response to suckling is essential for the maintenance of lactation. This physiological hyperprolactinaemia is also associated with lactational infertility. However, it is not clear whether there is any direct relationship between changes in prolactin per se and the duration of infertility. To address this question, our study determined the pattern of prolactin secretion in relation to suckling and the return of ovarian activity in the same cohort of breast-feeding women. Blood samples were withdrawn at 10 min intervals for 24 h from 09:00 to 09:00 h at either 4 (n = 9) or 8 weeks (n = 11) post-partum when the women had completely suppressed ovarian activity, at the time of the introduction of supplements to the baby (n = 17), a time associated with reduction of suckling activity, at first menses while still breast-feeding (n = 13) and in the follicular phase (n = 9) of the first menstrual cycle after weaning. During sampling, mothers and babies continued their normal pattern of suckling activity. The pattern of prolactin release was very variable at each stage of lactation, depending on the pattern of suckling. Frequent suckling was associated with elevated prolactin concentrations during the 24 h period throughout lactation. When suckling was less frequent, prolactin concentrations fell to baseline values between breast-feeds, but prolactin was released in response to all suckling episodes. An increase in prolactin concentrations at night, independent of suckling, was only evident once breast-feeding had ceased. The prolactin response to suckling declined significantly only after the return of menses at 33.6 +/- 3.5 weeks post-partum. There was no relationship between the duration of amenorrhoea and the plasma concentrations of prolactin over 24 h, or day or night separately, throughout lactation. However, there was a strong correlation (r = 0.843; P < 0.01) between the timing of the introduction of dietary supplements to the baby and the duration of amenorrhoea. These results suggest that there may be no precise link between the release of prolactin during lactation and the duration of lactational infertility in breast-feeding women.

Who gives advice about postpartum contraception?

Women were interviewed to determine what advice they received about postpartum contraception and what they thought of it. Only 4% of women discussed postpartum contraception antenatally. Up to 84% discussed the issue with a midwife on the postnatal ward but discussion was often felt to be brief, limited and frequently held as the mother was leaving the hospital. Obstetricians appeared to have little interest in the subject and only 50% of mothers left the hospital with supplies of a contraceptive. Almost all women discussed contraception with their general practitioner at the postnatal check but a significant number felt that the choice of method was limited to condoms or pills. The postnatal check is traditionally held at six weeks--two to three weeks after the recommended time for starting contraceptive precautions. Women with short inter-pregnancy intervals were younger, less likely to be married and more likely to default from postnatal follow-up. Pregnant women should be offered the opportunity during the antenatal period to discuss postpartum contraception with someone who has a special interest in the subject. The postnatal ward is not an appropriate setting for discussion about future contraception.

The relationship between decidualization and prolactin mRNA and production at different stages of human pregnancy

Within the human utero-placental unit only decidualized stromal cells express mRNA for prolactin. However, it is not clear if the level of prolactin production is related to the number of decidualized cells or the capacity of individual decidual cells to synthesize prolactin, either or both of which parameters may change during pregnancy. In the present study, prolactin production at different stages of human pregnancy was examined using quantitative in situ hybridization to assess decidual prolactin mRNA abundance, immunocytochemistry to examine the prolactin content inside decidual cells and RIA to measure decidual prolactin output into amniotic fluid. Throughout pregnancy the proportion of stromal cells showing positive immunostaining and mRNA for prolactin increased. There was a parallel increase in decidual cell size which was correlated with an increase in prolactin gene expression and intensity of immunostaining for prolactin in individual decidual cells. These changes in decidual cells were consistent with the changes in the concentration of prolactin in amniotic fluid. These results suggest that there is a close link between the level of prolactin gene expression and production of prolactin by individual decidual cells, which in turn is directly related to the process of decidualization that continues throughout human pregnancy.

Oral progestogen-only contraception may protect against loss of bone mass in breast-feeding women

BACKGROUND AND OBJECTIVES

A worldwide trend towards increasing life expectancy has meant that osteoporosis is emerging as an important public health problem. The loss of bone mineral density and its restoration in association with a premenopausal but physiological hypo-oestrogenic state may serve as an important model for research into the pathogenesis and prevention of osteoporosis. With this in mind we have undertaken a longitudinal study of changes in bone mineral density over one year in women after childbirth.

DESIGN

Observational study of 31 women in the first year following childbirth; 11 intending to breast-feed and use barrier methods of contraception, 9 intending to breastfeed and to use the progestogen-only pill and 10 intending to artificially feed and to use barrier methods.

PATIENTS

Recruitment was from the antenatal clinics of the Simpson Memorial Maternity Pavilion. Only non-smokers who had regular menstrual cycles prior to conception were included.

MEASUREMENTS

Bone mineral density was measured at the lumbar spine within 3 weeks of childbirth and repeated at 6 and 12 months post partum. Plasma oestradiol, prolactin and osteocalcin concentrations were measured at each visit.

RESULTS

Breast-feeding women using barrier methods lost a mean +/- SE of 4.9 +/- 1.5% of bone mineral density in the first 6 months following delivery. This was however reversible since by one year the bone mineral density was no different from that measured immediately post partum. Breast-feeding women using the progestogen-only pill lost a significantly smaller percentage of bone mineral density in 6 months and by one year bone mineral density was 2.95 +/- 0.75% higher than post partum. Artificially feeding women had a steady increase in bone mineral density in the first year and bone mineral density was on average 4.3 +/- 1.2% higher.

CONCLUSION

Breast-feeding results in a reversible reduction in spinal bone mineral density. The small amounts of gestagen in the progesterone-only pill would appear to protect against this loss. The mechanism of this loss in bone mineral density and the potentially bone protective effects of gestagens require further study.

Abnormal twenty-four hour pattern of pulsatile luteinizing hormone secretion and the response to naloxone in women with hyperprolactinaemic amenorrhoea

OBJECTIVE

Hyperprolactinaemic amenorrhoea is associated with disturbances of pulsatile gonadotrophin secretion. The underlying mechanism remains unclear and the aim of this study was to investigate the 24-hour secretory pattern of gonadotrophins in women with hyperprolactinaemic amenorrhoea. The effect of opioid blockade using naloxone infusion on LH secretory pattern was also studied.

DESIGN

The secretory patterns of LH, FSH, PRL and their responses to naloxone infusion were studied by serial blood samples collected at 10-minute intervals for 24 hours. On the following day, naloxone was infused at a dose of 1.6 mg per hour for 4 hours.

PATIENTS

Eight women with hyperprolactinaemic amenorrhoea, two women hyperprolactinaemic but with normal ovarian cycles, and nine control subjects in the early follicular phase of menstrual cycle.

MEASUREMENTS

Concentrations of LH, FSH and PRL were measured in plasma samples obtained at 10-minute intervals for 24 hours. In one woman, concentrations of urinary oestrone glucuronide were measured daily during treatment with pulsatile GnRH.

RESULTS

The number of LH pulses per 24 hours was significantly fewer in women with hyperprolactinaemic amenorrhoea than in those with hyperprolactinaemia with normal cycles or control subjects (mean +/- SEM 4.5 +/- 2.4 vs 13.5 +/- 2.5 vs 17.3 +/- 0.8, P < 0.001). The magnitude of each episode of secretion was significantly higher in the hyperprolactinaemic amenorrhoeic women (P < 0.05) so the overall mean concentrations of LH throughout the 24-hour period was similar in the three groups (5.2 +/- 1.1, 4.8 +/- 0.8 and 5.2 +/- 0.4 U/l respectively). In women with hyperprolactinaemic amenorrhoea there was no significant change in the pattern of LH secretion during sleep in contrast to the control women in whom there was a slowing in the LH pulse frequency during the night. There was no significant change in the mean concentrations of LH, FSH and PRL during the naloxone infusion. There were also no significant changes in the LH pulse frequency in response to naloxone infusion when compared with an equivalent period of time in the previous 24 hours. In one hyperprolactinaemic amenorrhoeic woman, follicular development, ovulation and pregnancy were induced when gonadotrophin releasing hormone (GnRH) was infused in a pulsatile manner at a dose of 5 micrograms every 90 minutes.

CONCLUSIONS

The suppression of normal ovarian cycles in women with hyperprolactinaemic amenorrhoea is due to a significant reduction in frequency of LH (GnRH) secretion which is not due to an increase in hypothalamic opioid activity. As normal ovarian cycles can occur or be induced by exogenous GnRH in hyperprolactinaemia, it is unlikely that a high level of prolactin by itself inhibits follicular development and ovulation.

Immunolocalization of oestrogen and progesterone receptors in the human decidua in relation to prolactin production

The distribution of oestrogen and progesterone receptors within the decidualized stroma of the uterus was examined in early and term human pregnancy and the results related to the effect of oestradiol and progesterone on prolactin production by decidua in vitro. In early pregnancy progesterone receptors were present in the nucleus of decidualized cells of both the capsularis and parietalis but not in glandular cells. In contrast at term progesterone receptors were located within the cytoplasm of decidual cells. Oestrogen receptors were detected only in the nucleus and were present in greater amounts in decidua capsularis than parietalis in early pregnancy, but were not detectable in term decidua. Both oestrogen and progesterone receptors were present in the nuclei of cells of arterioles within the decidua. In early pregnancy prolactin production decreased during in-vitro culture of decidua parietalis but was maintained in decidua capsularis, associated with an increase in progesterone production by the decidua capsularis. In term decidua, prolactin production in vitro was only stimulated by a combination of oestradiol and progesterone. These results suggest, firstly, that maintained decidualization and prolactin production by decidua capsularis during treatment of women in early pregnancy with the anti-progestin mifepristone is not due to an absence of progesterone receptor; secondly, there is a shift in immunoreactive progesterone receptor in decidual cells from the nucleus in early pregnancy to the cytoplasm in term pregnancy. This may indicate an alteration in the action of progesterone around the time of parturition; and thirdly, in term decidua, progesterone, apparently acting through the cytoplasmic receptor, is active in increasing prolactin production in vitro only when combined with oestradiol.

Effect of antagonists of dopamine and opiates on the basal and GnRH-induced secretion of luteinizing hormone, follicle stimulating hormone and prolactin during lactational amenorrhoea in breastfeeding women

The role of dopamine and opiates in the suckling-induced suppression of gonadotrophin secretion and prolactin release was investigated during lactational amenorrhoea in fully breastfeeding women at 12 weeks post-partum. A total of 26 women, 20 using non-steroidal methods of contraception and six using the progestogen-only pill, Noriday (POP), breastfed their babies on demand at a frequency of 3.6 +/- 0.2 suckling episodes during the 8 h study period while blood samples were collected at 10-min intervals. Five hours after the start of sampling six women were given the dopamine antagonist metoclopramide (10 mg, i.m.) while four women received saline. In a second experiment, six women using nonsteroidal contraception and three women on the POP received an i.v. infusion of the opiate antagonist naloxone (1.6 mg/h) for 2 h, while four women using non-steroidal contraception and three women on the POP were infused with saline. Two hours after the i.m. injection or start of infusion all women were given an i.v. injection of 10 micrograms gonadotrophin releasing hormone (GnRH) and samples were collected for a further 1 h. All samples were assayed for luteinizing hormone (LH), follicle stimulating hormone (FSH) and prolactin. Plasma concentrations of oestradiol were < 60 pmol/l in all women and they remained amenorrhoeic for at least 10 weeks after the study. Pulsatile release of LH was only observed over the 5 h pre-treatment period in 10 of the 20 non-steroid taking women (1-3 pulses/5 h), and in one of the six women (1 pulse/5 h) on POP.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between peripheral immunoactive inhibin, human chorionic gonadotrophin, oestradiol and progesterone during human pregnancy

OBJECTIVE

The objective of this study was to investigate serial changes in the plasma concentration of inhibin in both the very early days of pregnancy following implantation and in late pregnancy. The timing of the changes in inhibin concentration relative to changes in the concentrations of other hormones of pregnancy was also investigated.

DESIGN

Serial observations of the peripheral concentrations of inhibin and other hormones in two groups of healthy volunteers in (a) early pregnancy and (b) late pregnancy.

PATIENTS

(a) Four healthy women recruited on cessation of contraception prior to conception. (b) Nine healthy women recruited at the antenatal clinic.

MEASUREMENTS

In the early pregnancy subjects, the concentrations of inhibin, progesterone, oestradiol and hCG were measured in plasma samples obtained three times per week from day 8 to day 10 of each menstrual cycle until 11 weeks after the last menstrual period in the conception cycle. In the late pregnancy subjects, plasma samples were obtained at 4-week intervals from 12 weeks until term.

RESULTS

The concentration of inhibin, progesterone and oestradiol in conception cycles were similar to those in the preceding cycles until the mid/to late-luteal phase of the cycle when hCG was first measureable. By day 12 of the luteal phase the concentration of inhibin was significantly higher in the pregnancy cycle than in the non-pregnancy cycle (P < 0.05) and progressively increased after the time of the missed menstrual period. The concentration of inhibin reached a peak (513.0 U/l, CI 442.1-595.3) by day 47 when the concentration of hCG was maximal. In early pregnancy the concentration of inhibin was correlated with that of hCG (r = 0.361; P < 0.01) as well as progesterone (r = 0.584, P < 0.001) and oestradiol (r = 0.602, P < 0.001). After 12 weeks there was no significant correlation between hCG and inhibin although significant correlations persisted with progesterone (r = 0.553, P < 0.001) and oestradiol (r = 0.361, P < 0.01).

CONCLUSIONS

The corpus luteum makes a significant contribution to the production of inhibin in early pregnancy while after 12 weeks the placenta is the major source.

The 24 h pattern of pulsatile luteinizing hormone, follicle stimulating hormone and prolactin release during the first 8 weeks of lactational amenorrhoea in breastfeeding women

In women, breastfeeding results in a variable period of ovarian inactivity which is apparently related to suppression of the normal pulsatile release of luteinizing hormone (LH). However, pulse profiles had only been studied during the daytime. Since resumption of pulsatile LH secretion during puberty is initiated at night, the present study determined the pattern of pulsatile LH secretion in relation to that of follicle stimulating hormone (FSH) and prolactin, and suckling and ovarian activity at 4 and 8 weeks postpartum in 20 fully breastfeeding women with lactational amenorrhoea. Blood samples were withdrawn at 10 min intervals for 24 h from 0900 h to 0900 h at either 4 weeks (n = 9) or 8 weeks (n = 11) postpartum, while the mothers and babies continued their normal pattern of suckling activity. At 4 weeks postpartum, no LH pulses occurred over 24 h in six of the nine women while one (n = 1) or two (n = 2) LH pulses occurred in three of the nine women. In contrast, LH pulses were present in nine of the 11 women at 8 weeks postpartum. The pulse frequency varied considerably from two to eight pulses over the 24 h and there was no influence of the time of day or sleep on the time of the pulse release. Lactational amenorrhoea was maintained for at least 10 weeks afterwards and there was no relationship between the time of resumption of ovarian activity and the presence or absence of pulsatile LH secretion at 4 or 8 weeks postpartum.(ABSTRACT TRUNCATED AT 250 WORDS)

Localization of the sites of synthesis and action of prolactin by immunocytochemistry and in-situ hybridization within the human utero-placental unit

While the fetal pituitary synthesizes and releases prolactin, it is also produced within the utero-placental unit during pregnancy in women and has been localized in the amnion, chorion and decidua. However, it is not clear whether prolactin is synthesized within all these non-fetal pituitary tissues. We have investigated prolactin production and its gene expression using tissue culture, immunocytochemistry and in-situ hybridization techniques. Prolactin was immunolocalized not only in the decidua but also in amnion and trophoblast cells. In contrast, the in-situ hybridization results showed that silver grains, formed by specific hybridization of a prolactin cDNA probe to prolactin mRNA, were confined to decidual cells of early and term pregnancy. The results from tissue cultures correlated well with those of in-situ hybridization, that is that only the decidua made detectable prolactin, while it was undetectable in the culture medium from trophoblast tissue, irrespective of the stage of pregnancy. This study, for the first time, establishes that only decidualized cells are involved in biosynthesis of prolactin; other prolactin-containing cells in the amnion and trophoblast appear to sequester prolactin, possibly via receptors, suggesting that prolactin may play an important paracrine role within the amnion and syncitio- and cytotrophoblast of the utero-placental unit.

Effects of mifepristone in vivo on decidual prostaglandin synthesis and metabolism

Mifepristone is an effective abortifacient in combination with an exogenous prostaglandin but its mechanism of action is unknown. Mifepristone stimulates prostaglandin production from decidua in tissue culture. To determine whether this effect also operates in vivo, we treated women with mifepristone 24, 36 and 48 hours prior to surgical termination. Decidua was removed at operation and the ability of the tissue to generate prostaglandin in culture subsequently assessed. Pretreatment with mifepristone 36 hours prior to termination of pregnancy resulted in an increased production of PGF2 alpha in tissue culture (p less than 0.01). A significant decrease in PGFM production was seen 24 hours after pretreatment with mifepristone in vivo (p less than 0.01). These results suggest that the increased uterine activity observed after administration of mifepristone may be due to stimulation of endogenous prostaglandin production and inhibition of prostaglandin metabolism.

A comparison of the effects on follicular development between clomiphene citrate, its two separate isomers and spontaneous cycles

An investigation of the effects on follicular development of clomiphene citrate and its two isomers En clomiphene and Zu clomiphene given separately was carried out on 19 normally cycling women being treated with donor insemination. All women received clomiphene citrate in the first cycle and, following a washout control cycle, were treated with either En clomiphene or Zu clomiphene alone. The number of follicles present, follicular phase oestrogen secretion and luteal phase pregnanediol excretion were not significantly different when Zu clomiphene cycles were compared with control cycles, but were significantly increased in En clomiphene and clomiphene citrate cycles. It is concluded that the En isomer, which has largely antioestrogenic properties, is the isomer active in inducing follicular development. The oestrogenic properties of Zu isomer did not appear to protect it from the possibly detrimental effects on sperm-cervical mucus interaction observed in both isomers and in the combined preparation.

FSH and the control of follicular growth

During 70 days or so from the time of recruitment until just before the beginning of the cycle during which a follicle is destined to ovulate, folliculogenesis is a continuous process dependent on gonadotrophins but independent of the fluctuations in their concentrations occurring during this time. For follicle growth to continue beyond the 2-4 cell antral stage FSH concentrations must rise above a certain threshold level at the correct time. Once threshold levels are exceeded a single follicle becomes dominant suppressing FSH concentrations to subthreshold values. The period during which FSH concentrations are above threshold can be imagined as a gate through which a follicle must pass if it is to ovulate.

Glucose phosphate isomerase activity in mouse and human eggs and pre-embryos

We have measured the activity of glucose phosphate isomerase (GPI-1) in 12 unfertilized human eggs and five human pre-embryos relative to the GPI-1 activity in C57BL/OlaWs mouse eggs. The GPI-1 activity in the human eggs was approximately 6 times that in the C57BL mouse eggs. This implies that human eggs have approximately twice the activity per unit volume of the C57BL mouse eggs but no more than certain other strains of mice. The activity in five human pre-embryos, the most advanced of which was an early blastocyst, was similar to that seen in the human eggs. No change in GPI-1 activity was seen in mouse pre-embryos up to 2 1/2 days (8- to 12-cell stage) but the activity had declined by 3 1/2 days (compacted morula and early blastocyst stages). It seems that high levels of GPI-1 activity are maintained during the early preimplantation development of both species.

Sexing whole human pre-embryos by in-situ hybridization with a Y-chromosome specific DNA probe

We have used DNA-DNA in-situ hybridization with a DNA probe for the human Y-chromosome to distinguish between male and female human pre-embryos. Both biotinylated and tritiated Y-probes worked well on control cell cultures where 100 interphase nuclei were scored. Morphologically normal pre-embryos could be sexed with confidence with the tritiated Y-probe but the biotin results were less reliable (although only a few pre-embryos were analysed in this way). Early cleavage stage pre-embryos had large nuclei with relatively diffuse Y-bodies and were more difficult to score with the biotinylated Y-probe. Morphologically abnormal pre-embryos often had large nuclei with multiple Y-bodies (presumably polyploid nuclei) or small nuclei with no Y-bodies (possibly fragmenting nuclei). In all, 38 cleaving and two non-cleaving pre-embryos were analysed. The incidence of false positive and false negative cells seen after hybridization of tritiated Y-probes to control lymphocyte cultures suggests that it should normally be possible to distinguish morphologically normal male and female pre-embryos with samples of three to six interphase nuclei.

Effects of preovulatory tamoxifen in regularly cycling women on folliculogenesis, oocyte recovery and luteal function

Forty women undergoing elective sterilization and oocyte donation were randomized in a trial to study the effects of administration of 30 mg of tamoxifen 12 h before injection of human chorionic gonadotrophin and 48 h before oocyte capture. Cycles were regulated for advanced operative scheduling with norethisterone given in the luteal phase of the previous cycle and 150 mg of clomiphene given in the early follicular phase of the recovery cycle. Tamoxifen cycles showed a delay of peak urinary oestrone excretion by 2 days, associated with a slight decrease in total excretion. Tamoxifen administration lengthened treatment cycles by 0.5 days and the luteal phase by 0.4 days. The urinary excretion peak of pregnanediol was 3 days later than in controls. Total pregnanediol excretion was slightly elevated. There were no differences in oocyte recovery rate although cleavage rate was decreased (0.84 versus 0.65, not significant at P greater than or equal to 0.05). Intrafollicular oestradiol levels were similar (794 +/- 97 versus 735 +/- 102 ng/ml). Intrafollicular progesterone levels were marginally lower in tamoxifen cycles (3.5 +/- 0.5 versus 2.3 +/- 0.8 micrograms/ml).

A comparison of dosages of norethisterone for synchronization of cycles in a fixed regimen of follicular augmentation and in vitro fertilization

Twenty-four patients undergoing elective laparoscopic sterilization were randomized in a fixed schedule of follicular augmentation, oocyte recovery, and in vitro fertilization (IVF) using either 2.5 or 10 mg of norethisterone (NE) in the luteal phase of the previous cycle. The objectives of the study were to determine the effect of a synthetic progestin, given for 5 to 14 days beginning on day 21 of the cycle before the IVF cycle, on folliculogenesis, estrogen secretion, the luteinizing hormone (LH) surge, luteal function, and IVF success. It was found that this treatment was easy to administer and well tolerated by patients. At the 10-mg dose, patients uniformly had vaginal bleeding 2 to 4 days after NE, whereas 40% of patients using the 2.5-mg dose bled before NE was discontinued. Significantly lower estrone glucuronide excretion in the early follicular phase and lower luteal phase pregnanediol excretion in patients receiving 10 mg NE suggested a delay or reduction of developing follicles after luteal phase suppression. No spontaneous LH surges were found in the 10-mg group, compared with surges in 5 of the 13 cycles of the 2.5-mg group. There were no differences between regimens in cycle or luteal phase length. It is postulated that NE, by suppressing folliculogenesis in the luteal phase, may provide for a smaller, but more homogenous cohort of follicles available for exogenous stimulation and recovery.

Does treatment with bromocriptine influence the course of hyperprolactinaemia?

Twenty-two women with hyperprolactinaemia without evidence of microadenoma, either untreated (n = 3), treated with bromocriptine for a total of less than 1 year (n = 12), or treated with bromocriptine for a total of more than 1 year (n = 7) were followed up by retrospective case-note review for at least 53 months. More than 50% of the women showed a fall in serum prolactin concentrations by more than 40% over the period of follow-up. The occurrence of a fall did not appear to be related to either length of treatment with bromocriptine or to the occurrence of pregnancy. Some women elected to remain untreated, despite symptoms, in preference to taking tablets and having to use contraception. The wisdom of leaving patients untreated in the light of these findings is discussed.

Post-fertilization polyploidy in human preimplantation embryos fertilized in-vitro

The development of in-vitro fertilization (IVF) and embryo transfer (ET) as a treatment for certain forms of infertility has emphasized the need for more information on why so many preimplantation embryos fail to develop beyond the very early cleavage stages. Analysis of nuclei from embryos that had ceased to grow or that were morphologically abnormal was carried out using one of two techniques: measurement of the DNA content of their nuclei, or observation of the number of Y chromosomes per nucleus. It was found that there was a correlation between the length of time in culture and abnormal development of polyploidy in a number of the cells. On the other hand, a small proportion of polyploid cells observed in a morphologically normal expanded blastocyst probably represents the normal precursors of polyploid trophoblast cells as observed in other mammalian species.

Sexing the human pre-embryo by DNA-DNA in-situ hybridisation

Human male pre-embryos were identified by means of DNA-DNA in-situ hybridisation with a commercially available DNA probe for Y-chromosome DNA. This method could lead to prenatal diagnosis of genetic disorders based on small numbers of cells that are not necessarily in division, such as cells obtained from a pre-embryo during the course of in-vitro fertilisation therapy.

Relative ability of modified versions of the hamster oocyte penetration test, incorporating hyperosmotic medium or the ionophore A23187, to predict IVF outcome

This study was designed to assess the relationship between IVF outcome and the results obtained with two modified versions of the zona-free hamster oocyte penetration test in which the spermatozoa were pre-incubated with either hyperosmotic medium or the divalent cation ionophore A23187. When the former system was used, a poor correlation with IVF outcome was observed. Samples screened prior to IVF exhibited a 60% false negative rate (failed penetration test, successful IVF), while for those assessed concurrently with IVF, the equivalent figure was 85.7%. Addition of A23187 optimized the penetration system giving higher levels of sperm--oocyte fusion and a more accurate prediction of the capacity of the spermatozoa to fertilize human ova in vitro. With this system the false negative rate was 4.3% for screened samples and 0% for those assessed simultaneously with IVF. These results suggest that the A23187-enhanced system may be of value as a screening criterion for IVF.

Fertility after childbirth: pregnancy associated with breast feeding

During studies on the resumption of fertility postpartum in 12 breast feeding mothers who were using no contraception, eight pregnancies occurred. In seven cases these pregnancies occurred while the mothers continued to breast feed while in one it occurred within 2 weeks of weaning. In two cases pregnancy occurred prior to first postpartum menstruation but followed an abrupt decline in suckling frequency and duration resulting in resumption of follicular development and ovulation. In the remaining six cases, pregnancy was preceded by between 1 and 7 menstrual cycles, the majority of which (13/19) had deficient luteal phases or were anovular (4/19). In all mothers a significant decrease in the suckling frequency and duration observed during lactational amenorrhoea had occurred prior to the resumption of ovulation and conception. No mother conceived with a suckling frequency of greater than three times per day although some mothers ovulated without conceiving when suckling four times per day. The results suggests that if a breast feeding mother wishes to rely upon the infertility associated with lactational amenorrhoea, she must suckle at least five times per day with a total suckling duration of more than 65 min per day (more than 10 min per feed). Any reduction below either of these limits may result in a return of fertility.